Spinal Cord Stimulator Infection: Approach to Diagnosis, Management, and Prevention

Abstract

Spinal cord stimulation (SCS) is the most utilized invasive electrical neuromodulation treatment for the management of refractory chronic pain syndromes. Infection is one of the most dreaded complications related to SCS implantation and may prevent patients from receiving adequate pain treatment, adding to the initial cost and disability. Most SCS infections present as generator pocket infection. However, delay in diagnosis may lead to complications such as meningitis, epidural abscess, and/or vertebral osteomyelitis. Early recognition of SCS-related infections and associated complications is based on clinical suspicion, laboratory testing, and appropriate diagnostic imaging. While superficial surgical site infection following SCS implant may be treated with antibiotic therapy alone, deep infection involving implant warrants device removal to achieve cure. Duration of antimicrobial therapy depends on severity of clinical presentation and presence or absence of associated complications. Several preventive strategies can be incorporated in surgical practice to reduce the risk of SCS infection.

Outcomes Associated With Infection of Chronic Pain Spinal Implantable Electronic Devices: Insights From a Nationwide Inpatient Sample Study

“…In this large nationwide study of hospitalized patients with CPSIED infections, the majority of the patients did not undergo device removal procedures. This is contrary to other device‐related infection practices that we see in cardiovascular implantable electronic device (CIED) infections (7), ventriculoperitoneal shunt infections (8), and results from other studies on SCS infections (6). The underlying reasons for the nonremoval of the CPSIED system could not be ascertained from the NIS database.…”

“…Superficial SSIs are treated with a short course of pathogen directed antibiotics for 7-10 days. Deep complicated SSIs and superficial SSIs that do not respond to a course of antibiotics are best treated with complete hardware removal (6).…”

Evaluating the incidence of spinal cord injury after spinal cord stimulator implant: an updated retrospective review

“…Some additional complications of SCS implant include surgical site infection, poor wound healing, and lead migration 6 14 15. For the most part, these are generally treatable, reversible, and in some cases, avoidable, with appropriate surgical technique.…”

“…The SCS implant can be placed either percutaneously, in which electrodes are fluoroscopically guided to their desired location in the epidural space, or through paddle leads where they are placed under direct target visualization via laminectomy or laminotomy. While increasingly safe with a low risk of complications, common risks associated with these procedures include surgical site infection, poor wound healing,6 14 15 and lead migration 6. However, one of the most feared complications associated with SCS is spinal cord injury (SCI), but literature regarding its incidence remains highly variable, ranging from 0.5% to 2.13%, and is now largely outdated 16–18…”

Successful Reimplantation of Spinal Cord Stimulator One Year after Device Removal Due to Infection

“…Although only seen in ∼2.45% of SCS implants, infected devices are some of the most dreaded complications and add the risk of meningitis, epidural abscess, and vertebral osteomyelitis. 2 3 It is crucial for physicians to recognize potential infections in a timely manner to prevent these more serious adverse effects. After explantation and initiation of antibiotic coverage, the question remains; what is the appropriate time to wait to reimplant?…”